Midwifery comes of age in Ontario

20 years after regulation, midwives outnumber obstetricians and launch two birth centres

Maryjane Tait gave birth to baby Ethan while surrounded by extended family and friends at the Toronto Birth Centre. It was the centre's first aboriginal birth, celebrated with drumming and a traditional welcome song.

There is an altered state women reach in the throes of natural childbirth when the body takes over and every ounce of energy is turned inwards, absorbed by its clenching rhythm. All one can do is breathe, endure, cry out, breathe again.

Maryjane Tait had reached that place early one evening when she became vaguely aware of another beat pulsing in the distance. It sounded faintly like a drum.

“I thought I heard something. Then I thought maybe I was imagining it,” recalls Tait.

She wasn’t. While Tait was gripped by contractions in the Cedar Room of the Toronto Birth Centre, upstairs a group of Métis women were holding a book launch and participating in a drumming circle.

After she delivered six-pound, nine-ounce Ethan at 7:23 p.m., the drummers played a traditional welcoming song to honour the baby, joined by almost 50 singers.

“It was a truly good gift,” says Tait, 30, whose roots are Ojibwe, Mohawk and Gitxsan and who was tended by three aboriginal midwives.

In keeping with her culture, she was surrounded by extended family and friends throughout her six-hour stay at the birth centre in Regent Park. They paced the spacious halls with her as labour progressed. They rubbed her back as she lay in the glow of the gas fireplace. They brought groceries to the communal kitchen, baked lasagna and passed around plates of fruit.

Almost a dozen people were in the room to hear the baby’s first cry on February 12.

“It meant a lot that my baby was born with such a good vibe and the positive spirits of so many people,” says Tait. “It felt like everything around us was in sync.”

For midwife Sara Wolfe, who practises with Seventh Generation Midwives Toronto, the birth was a symbol of how far midwifery has come in providing Ontario women with choices in childbirth and in honouring the traditions of groups who’ve long been overlooked.

“It was very powerful. The fact that she had all those people around her to welcome the baby into the world was special and unique. You don’t get that in a hospital.”

Hospitals have also come a long way in providing comfortable settings and more options for women having babies. And more than three-quarters of women cared for by midwives have hospital births, while the rest choose to deliver at home.

But the new birth centre, run by midwives, offers a third alternative for women with low-risk pregnancies who want natural childbirth out of hospital.

It also has safeguards in place in case complications arise during labour or a woman decides she an epidural or other measures midwives can’t administer. A street-level emergency exit, designed with the help of Toronto EMS, allows them to get to a downtown hospital in a matter of minutes.

This year is the 20th anniversary of modern midwifery — in 1994 midwives joined the province’s health care system as a regulated profession covered by OHIP. Two pilot birth centres — the second one is in Ottawa — opened in time to celebrate the occasion and are landmarks in the modern midwifery movement.

They are among many signs of midwifery’s evolution in the last two decades.

Although midwives are only credited with 6 per cent of deliveries, they care for 12 to 14 per cent of pregnant women and are turning away clients because they can’t meet the demand, according to the Association of Ontario Midwives. The difference reflects women whose care was transferred to an obstetrician.

At the three universities that offer four-year midwifery degrees — Ryerson University in Toronto, Hamilton’s McMaster University and Sudbury at Laurentian University — competition is fierce to land one of the 90 spots available in the province each year.

In 2011, Carol Cameron became the first midwife to run a hospital birth unit. During her two-year term as clinical director of the childbirth centre at Markham Stouffville Hospital, she was part of a successful project to reduce caesarean-section rates. She helped initiate such practices as immediate skin-to-skin contact between moms and babies after birth, which improves infant health and bonding and has long been a standard in midwifery.

It’s a far cry from the midwifery of 40 years ago, when the practice was an underground movement and, for many people, conjured up images of a bleak Dickensian era.

“It’s not that we’ve arrived, it’s that we’re on board,” says Bridget Lynch, who recently spent three years at the helm of the 300,000-member International Confederation of Midwives, where she helped put maternal and infant health care in developing countries on the G8 agenda.

The progress “is pretty remarkable,” adds Eileen Hutton, a nurse and midwife during those early days and now assistant dean of midwifery at McMaster.

As the self-proclaimed “experts on normal birth,” midwives have also influenced childbirth practices. Hutton cites delayed clamping of the umbilical cord after birth and techniques such as perineal massage that have sharply reduced perineal tearing and, in turn, episiotomy rates.

They continue to argue that “normalizing” low-risk births — which constitute the majority of labours and deliveries — and moving them out of hospitals would save money and reduce the use of such interventions as epidurals and inductions, which are associated with higher caesarean-section rates.

Trained nurse-midwives have long been an anchor of British maternal health care — as brought to life recently by the smash hit BBC series Call the Midwife, set in postwar London.

That was not the case in Canada.

The trend toward medicalization in the early 1900s made childbirth a hospital event and soon relegated midwifery to isolated outposts and the aboriginal communities that kept the tradition alive, passing down wisdom informally through generations of practice.

With the feminist stirrings of the ’60s and ’70s, however, came an urge among many boomer women to reassert control over the experience.

A home birth movement started to rumble and with it the rebirth of midwifery.

“I think it was truly a reclamation of our bodies,” says Lynch, whose journey to become a midwife began after the disappointing hospital birth of her eldest child in 1974.

“We were going to do it differently from our own mothers.”

In the late ’70s and early ’80s, clutches of mothers and midwives began gathering in living rooms around the province to strategize and share resources as they breastfed babies and stepped over toddlers.

Some were encouraged by handful of family doctors who attended home births with young midwives in tow, recalls Mary Sharpe, who started practising in Toronto in 1979 and is now director of Ryerson’s midwifery program.

Midwives charged anywhere from $1,000 to $1,500 for care, which includes pregnancy and the six weeks postpartum, but also accommodated those who couldn’t afford their fees. Clients would even barter food or carpentry in return for midwifery services.

Two key events changed the landscape. In 1985, a coroner’s inquest into the death of a newborn following a home birth recommended that midwives become regulated in Ontario. That coincided with news that the province would review legislation governing all health care professions, which opened the door for midwives to submit a proposal.

Lynch says key to their success was the decision to merge two groups — midwives and nurse-midwives who had trained primarily in Britain — and build strength in unity.

Launched 30 years ago, their joint organization, the Association of Ontario Midwives, mapped out the professional standards and education model that would, in 1994, make them the first regulated midwives in Canada.

“It took a little over 10 years for midwives to go from obscurity to official recognition,” wrote Ivy Lynn Bourgeault of the University of Western Ontario in a 2000 paper on the impact of integrating midwifery into the system.

“This is a remarkably short period of time for such an achievement.”

When Rebecca Rutherford entered the world following an ice storm on Jan. 28, 1994, there were no drums or singers to welcome her.

But there were television cameras and reporters stationed outside the delivery room at Markham Stouffville Hospital.

They were eagerly awaiting the first baby to be born in an Ontario hospital without a doctor. Instead, midwives Carol Cameron and Peggy Cannon were attending. And thanks to new legislation, Anita and Paul Rutherford wouldn’t be out of pocket.

“I knew there were reporters in the hall while I was trying to push her out,” recalls Anita, 53.

But she wasn’t fazed. Although it was her first time in a midwife’s care, this was her fourth baby.

Cameron remembers it as a straightforward “dream birth,” ideal for the occasion.

Soon after delivering her 7-pound 2-ounce daughter, Anita put on her lipstick and faced the cameras to mark the historic moment. Everything was managed in time for the six o’clock news.

Since then, 180,000 babies have been born in the care of midwives at homes and hospitals in the province.

The new birth centres could mark the beginning of another phase. Each facility is expected to handle about 450 births a year.

The $12-million pilot project will be studied over the next five years to assess its cost-effectiveness compared to hospitals and to track outcomes for moms and babies.

If successful, it could pave the way for more birth centres to open across the province.

Researchers like Hutton predict a shift over the long-term that would give midwives a bigger role in uncomplicated births, leaving those trained in high-risk pregnancies to handle the most complex cases.

“I suspect we will head toward a model that we see in most jurisdictions around the world where midwives provide care to low-risk women and obstetricians are specialists,” she says.

As of April 30 the Toronto Birth Centre had admitted 55 women in labour. Seven of those were transferred to hospital for delivery.

This week centre recorded its 50th birth since its Jan. 31 opening and 293 women had made plans to deliver there.

The Ottawa Birth and Wellness Centre had 31 admissions by April 30, including 10 who transferred to hospital, and 200 bookings.

Equally important to midwives like Sara Booth are the women behind those numbers.

“Our goal is that 50 per cent of our clients come from priority populations,” says Booth, clinical director of the Toronto Birth Centre.

The 80 midwives who use the centre have the potential to reach women who aren’t getting the prenatal and postnatal care they need to keep themselves and their babies healthy. They may be poor, homeless, teens or newcomers without health insurance. They may be aboriginal, or from LGBTQ communities or other groups that feel shut out of the mainstream system and don’t know where to turn for care.

For Maryjane Tait, a birth experience that incorporated her aboriginal roots wasn’t the only important

part of her midwifery care. The six weeks of postpartum visits and consultations helped her breastfeed successfully after having problems when Ethan wouldn’t latch on.

The trio of midwives from the Seventh Generation practice showed her new feeding positions, techniques and offered constant encouragement.

“He feeds well now,” says Tait. “I don’t know what I would have done without the midwives.”

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